Clinician Article
Efficacy of antiplatelet therapy in secondary prevention following lacunar stroke: pooled analysis of randomized trials.
PMID: 25721018
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Family Medicine (FM)/General Practice (GP)Relevance - 6/7
Newsworthiness - 6/7 -
General Internal Medicine-Primary Care(US)Relevance - 6/7
Newsworthiness - 6/7 -
Internal MedicineRelevance - 5/7
Newsworthiness - 6/7 -
NeurologyRelevance - 5/7
Newsworthiness - 4/7
Abstract
BACKGROUND AND PURPOSE: Lacunar stroke accounts for ˜25% of ischemic stroke, but optimal antiplatelet regimen to prevent stroke recurrence remains unclear. We aimed to evaluate the efficacy of antiplatelet agents in secondary stroke prevention after a lacunar stroke.
METHODS: We searched MEDLINE, Embase, and the Cochrane library for randomized controlled trials that reported risk of recurrent stroke or death with antiplatelet therapy in patients with lacunar stroke. We used random effects meta-analysis and evaluated heterogeneity with I(2).
RESULTS: We included 17 trials with 42,234 participants (mean age 64.4 years, 65% male) and follow up ranging from 4 weeks to 3.5 years. Compared with placebo, any single antiplatelet agent was associated with a significant reduction in recurrence of any stroke (risk ratio [RR] 0.77, 0.62-0.97, 2 studies) and ischemic stroke (RR 0.48, 0.30-0.78, 2 studies), but not for the composite outcome of any stroke, myocardial infarction, or death (RR 0.89, 0.75-1.05, 2 studies). When other antiplatelet agents (ticlodipine, cilostazol, and dipyridamole) were compared with aspirin, there was no consistent reduction in stroke recurrence (RR 0.91, 0.75-1.10, 3 studies). Dual antiplatelet therapy did not confer clear benefit over monotherapy (any stroke RR 0.83, 0.68-1.00, 3 studies; ischemic stroke RR 0.80, 0.62-1.02, 3 studies; composite outcome RR 0.90, 0.80-1.02, 3 studies).
CONCLUSIONS: Our results suggest that any of the single antiplatelet agents compared with placebo in the included trials is adequate for secondary stroke prevention after lacunar stroke. Dual antiplatelet therapy should not be used for long-term stroke prevention in this stroke subtype.
Clinical Comments
Family Medicine (FM)/General Practice (GP)
As a family physician with many elderly patients, I find this important to know, particularly since it appears that the less expensive medicine - aspirin - may be equally as effective as newer more expensive medicines.
General Internal Medicine-Primary Care(US)
This article is definitely relevant. It provides useful information that most practitioners do not already know. The one criticism of the study, which the authors indicate as well, is the heterogeniety of the studies included in the pooled analysis.
Internal Medicine
Would not change what people do.
Internal Medicine
This is an important and clinically relevant paper.
Neurology
My thought is that this meta-analysis of antiplatelet therapy after ischemic stroke focuses after lacunar subtype of ischemic stroke. While academically interesting, it may not be an important distinction for most practicing physicians, including neurologists. The conclusion follows antiplatelet benefit and risks in stroke prevention in general. Antiplatelets reduce strokes by ~ 25%, while differences among them are small and difficult to discern, if at all. Dual antiplatelet therapy offers no clear benefit in the long-term.
Neurology
Although the study confirms the common practice of using antiplatelets in the secondary prevention of lacunar stroke, there is no advantage of one antiplatelet drug over another. The composite outcome was not affected, indicating its complex, multifactorial aspect.
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